Saturday, January 30, 2010

The cases I did not do

Just in case you are thinking this is all about partying in Rwanda, a bit more about work.
In some ways the cased I declined to do say more about the situation here than the ones I did.

On the first day they wanted me to do a 3 day old 3 kg baby for a bowel resection. I declined, and a local staff anesthesiologist did the case expertly, although there was confusion about the dose of narcotics so the patient got a double dose and had to be ventilated in the neonatal ICU postoperatively.

At CHUK there was a child with some sort of congenital cyanotic heart disease who had an ejection fraction of 20% and ventricular hypertrophy. In the absence of a cardiac echo expert this was all the information we had. He weighed 11 kg and needed a craniotomy for a brain abcess. His O2 sat was 85% on 5 l oxygen. I did not offer to do the case. Later that day I found him being operated on under local, with puss coming out of his brain. A nurse anesthetist was monitoring his saturation, but not his blood pressure or ECG. There was no medical anesthesiologist in sight. He seemed to be doing remarkably well.

The last couple of days inButare I saw some tragic cases. A child of about 7 who had a neglected ulcer on his leg which had become gangrenous, and now required an above-knee amputation. He had malaria, with a spleen below his umbilicus, and looked very pale. After discussion with a local staff anesthesiologist, I decided we should wait for a blood count and possible transfusion before operating. I came back from seeing the next day's patients to find the anesthesia techs intubating the child. Four hours after it was requested, the blood count result had not come back, but the techs did not seem to mind that.

There was a 22 year old guy who had had something fall on him, resulting in a complete fracture dislocation of his neck at C5 with complete quadriplegia. He could shrug his shoulders but not move his arms or legs. The surgeon wanted to fix the bones of his neck, but no-one, no-where can ever make his spinal cord work again.

He came to the operating room in respiratory failure. With only the diaphragm to breathe with he was retaining secretions, and could not cough. He was tachypnoiec, had a fever, and his oxygen saturation on room air was 74%. I explained to the surgeon that it was no problem to give him an anesthetic but that once we had intubated hiom there was no way we would be able to get him off the ventilator. He did not have the strength to breathe on his own now, and would never regain it. At best, he would live on a ventilator, totally dependant on others, until pneumonia, kidney failure or bed sores killed him. After much discussion with the surgeon and the local intensivist I got the case cancelled and he was returned to the floor for palliative care. The surgeon was a Cuban, and I had didfficulty understanding him in either English or French, but he seemed OK with this provided it was explained that the problem was that anesthesia did not have the facilities to look after the case post-operatively.

We then did an 11 kg child with a huge subdural on one side and a brain abcess on the other. I was quite comfortable letting the Rwandan residents do this case, partly beacuse they actually prepared in advance a list of all the drugs and equipment they needed, and partly because the child had virtually no functioning brain left and could not be made much worse!

The other case done in Butare that day was a 2,3 kg, 16 day old, baby for an omphalocoele. This was expertly done by a local staff anesthesiologist. You have to have nerves of steel to do a case like that with the best equipment in the world. To do it with an Oxford Miniature Vapouriser, Halothane, an Ayres T piece and no agent or CO2 monitoring takes real skill and guts.

I had one easy case in Butare this week - an adult woman with an ovarian cyst. This seemed to good to be true, until I saw the anesthesia equipment. They had basically cannibalised two anesthesia machines to make one that worked, provided you knew how to connect them together. The resident had no clue, but fortunately I was able to find a local staff anesthesiologist to show me how to connect things up.

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